Inspection Reports for Lillian G Carter Health and Rehabilitation

An abbreviated/partial extended survey was conducted to investigate complaint GA00255514.

The complaint GA00255514 was unsubstantiated and no regulatory violations were cited during the survey.

Complaint GA00255514 was unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint number GA00250510.

The complaint was substantiated, but no deficiencies were cited during the investigation.

Complaint number GA00250510 was substantiated.

This document is a Statement of Deficiencies and Plan of Correction for Lillian G Carter Health and Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A health revisit survey was conducted to verify correction of all deficiencies cited during the Recertification survey conducted on March 10, 2024.

All deficiencies cited in the prior Recertification survey have been corrected.

A Life Safety Code revisit survey was conducted to verify correction of previously cited survey tags.

All previously cited survey tags from the prior Life Safety Code survey were noted to have been corrected during this revisit survey.

A standard routine survey was conducted to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility was found not in substantial compliance with multiple deficiencies including failure to ensure PASARR Level II referral, incomplete comprehensive care plans for several residents, inadequate tracheostomy care supplies, failure to monitor psychotropic medication side effects, and ineffective infection control related to labeling and storage of personal care equipment.

The inspection was conducted as a State Licensure survey from March 8 through March 10, 2024, to determine compliance with the State Long Term Care Requirements.

Deficiencies were cited related to failure to monitor behaviors and side effects of psychotropic medications for one resident, failure to maintain an effective infection control program regarding labeling and storage of personal care equipment, and failure to develop and implement comprehensive, person-centered care plans for three residents regarding pain, diabetes and insulin usage, and monitoring behaviors on psychotropic medications.

The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including fire safety and sprinkler system standards.

The facility was found not in substantial compliance with emergency preparedness requirements and life safety code standards, including failure to ensure staff familiarity with the emergency plan, inadequate hazardous area enclosure, sprinkler head obstruction, and sprinkler heads not free of paint and corrosion.

An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00234515 and GA00233416.

No deficiencies were cited related to the complaints during the survey.

The survey investigated complaints GA00234515 and GA00233416; no deficiencies were found related to these complaints.

The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility failed to report complete COVID-19 information to the CDC's NHSN between 05/15/2023 and 05/21/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.

The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 05/08/2023 and 05/14/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

A state monitoring visit was conducted at Lillian G. Carter Health and Rehabilitation on 09/08/2022 to assess compliance with nursing home program requirements.

The facility was found in compliance with nursing home program requirements during the monitoring visit.

An Abbreviated Survey in conjunction with a Monitoring Survey was conducted to investigate Complaint Intake GA00226383.

No deficiencies were cited during the survey.

Complaint Intake GA00226383 was investigated and found to have no deficiencies.

A state monitoring visit was conducted at Lillian G Carter on 9/1/2022 to assess compliance with nursing home program requirements.

The facility was found in compliance with nursing home program requirements during the monitoring visit.

The document is a statement of deficiencies and plan of correction for Lillian G Carter Health and Rehabilitation facility, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A Revisit Survey was conducted to verify correction of deficiencies cited in the May 19, 2022 Recertification Survey.

All deficiencies cited in the May 19, 2022 Recertification Survey were found to be corrected during this revisit survey.

An abbreviated/partial extended survey was conducted to investigate complaint number GA00225135.

The complaint was unsubstantiated and no regulatory violations were cited during the investigation.

Complaint number GA00225135 was investigated and found to be unsubstantiated with no regulatory violations cited.

A licensure survey was conducted at Lillian G. Carter Health and Rehabilitation from 5/17/2022 through 5/19/2022 to assess compliance with State Licensure Regulations.

The facility was found to be in substantial compliance with State Licensure Regulations and no State Health deficiencies were cited.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.

The document is a statement of deficiencies and plan of correction for Lillian G Carter Health and Rehabilitation facility, indicating a regulatory inspection was conducted.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey of 12/16/2021.

The revisit survey found that all deficiencies cited as a result of the complaint survey had been corrected as of 1/30/2022.

The revisit survey was conducted following a complaint survey dated 12/16/2021. All deficiencies from that complaint survey were corrected by 1/30/2022.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00214039, GA00214235, and GA00214644.

Complaints GA00214039 and GA00214235 were unsubstantiated. Complaint GA00214644 was substantiated, but no State Health Deficiencies were cited.

Investigation of complaints GA00214039, GA00214235, and GA00214644; GA00214039 and GA00214235 unsubstantiated, GA00214644 substantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00214039, GA00214235, and GA00214644. Complaints GA00214039 and GA00214235 were unsubstantiated, while complaint GA00214644 was substantiated.

The facility failed to document weekly wound assessments and treatment administration for two of three residents reviewed for pressure ulcers. Additionally, the Quality Assurance and Performance Improvement Committee failed to effectively develop, implement, and monitor a corrective action plan related to documentation omissions for wound care.

Complaints GA00214039 and GA00214235 were unsubstantiated. Complaint GA00214644 was substantiated with deficiencies related to wound care documentation and QAPI effectiveness.

An abbreviated/partial extended survey was conducted to investigate complaint GA00211016.

The complaint was investigated and found to be unsubstantiated.

Complaint GA00211016 was investigated and determined to be unsubstantiated.

A COVID-19 Focused Infection Control Survey was conducted from 12/28/2020 through 12/29/2020 to assess the facility's compliance with infection control regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00200718 and #GA00201232.

The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.

Complaints #GA00200718 and #GA00201232 were investigated and found to be unsubstantiated.

The visit was conducted as a complaint investigation for complaint GA00204615, including a desk review from 5/4/2020 through 5/14/2020 and a COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey on July 8, 2020.

No deficiencies were cited during the COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey. No abuse, neglect, or immediate jeopardy concerns were noted at the time of the investigation.

Investigation by desk review of complaint GA00204615 was conducted including interviews and review of facility documentation. Onsite activities were not executed due to lack of access but will resume later. No abuse, neglect, or immediate jeopardy concerns were noted.

A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices for COVID-19.

A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2019-05-02.

All deficiencies cited as a result of the Recertification survey conducted on 2019-05-02 were found to be corrected during the revisit survey on 2019-06-24.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

The follow-up survey noted that all previously cited survey tags have been corrected.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance due to failure to protect cooking equipment in accordance with NFPA 96 standards, specifically the NFPA 96 hood did not provide a 6-inch overhang on the side of the stove, which could place kitchen staff at risk in the event of a kitchen fire.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

The follow-up survey noted that all previously cited deficiencies had been corrected.

A standard survey was conducted at Lillian G. Carter Healthcare and Rehabilitation from March 5, 2018 through March 8, 2018 to assess compliance with Medicare/Medicaid regulations.

The facility was found to be in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.

The visit was a Life Safety Code Survey conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with fire safety requirements due to lack of approved fire sprinkler coverage in the attic area above the smoking porch and absence of a remote annunciator for the emergency power generator. These deficiencies could put residents at risk in the event of fire or power failure.

The inspection was conducted to investigate complaint #GA00183377 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

Complaint #GA00183377 was investigated and found to have no deficiencies.

The inspection was conducted to investigate complaint #GA00181443 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

Complaint #GA00181443 was investigated and found to have no deficiencies.

The inspection was conducted to investigate complaint #GA00178304 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

Complaint #GA00178304 was investigated and found to have no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited during the 3/09/17 Standard Survey.

All deficiencies cited as a result of the 3/09/17 Standard Survey were found to be corrected.

A follow-up inspection was conducted to verify correction of previously cited deficiencies.

All previously cited survey tags have been corrected as noted by the follow-up inspection.

An Abbreviated Survey was conducted to investigate Complaint GA 00172886.

The facility was found to be in substantial compliance with Federal and State Long Term Care Requirements. No citations were cited.

Investigation of Complaint GA 00172886; no citations were cited indicating no substantiated deficiencies.

A Life Safety Code Survey was conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA Life Safety Code 2012 edition.

The facility was found not in substantial compliance due to failures in smoke barrier construction and smoke barrier doors. Specifically, smoke barriers were not properly sealed with approved fire stop materials, and smoke barrier doors did not meet the required 1 and 3/4 inch fire-resistant construction for at least 20 minutes, placing all 91 residents at risk in the event of a fire.